Robotic Esophagectomy. A Systematic Review with Meta-Analysis of Clinical Outcomes.

Background: Robot-Assisted Minimally Invasive Esophagectomy is demonstrated to be related with a facilitation in thoracoscopic procedure. To give an update on the state of art of robotic esophagectomy for cancr a systematic review with meta-analysis has been performed. Methods: a search of the studies comparing robotic and laparoscopic or open esophagectomy was performed trough the medical libraries, with the search string "robotic and (oesophagus OR esophagus OR esophagectomy OR oesophagectomy)". Outcomes were: postoperative complications rate (anastomotic leakage, bleeding, wound infection, pneumonia, recurrent laryngeal nerves paralysis, chylotorax, mortality), intraoperative outcomes (mean blood loss, operative time and conversion), oncologic outcomes (harvested nodes, R0 resection, recurrence) and recovery outcomes (length of hospital stay). Results: Robotic approach is superior to open surgery in terms of blood loss p = 0.001, wound infection rate, p = 0.002, pneumonia rate, p = 0.030 and mean number of harvested nodes, p < 0.0001 and R0 resection rate, p = 0.043. Similarly, robotic approach is superior to conventional laparoscopy in terms of mean number of harvested nodes, p = 0.001 pneumonia rate, p = 0.003. Conclusions: robotic surgery could be considered superior to both open surgery and conventional laparoscopy. These encouraging results should promote the diffusion of the robotic surgery, with the creation of randomized trials to overcome selection bias.

A systematic review and analysis of factors associated with methodological quality in laparoscopic randomized controlled trials.

Several methods for assessment of methodological quality in randomized controlled trials (RCTs) have been developed during the past few years. Factors associated with quality in laparoscopic surgery have not been defined till date. The aim of this study was to investigate the relationship between bibliometric and the methodological quality of laparoscopic RCTs. The PubMed search engine was queried to identify RCTs on minimally invasive surgery published in 2012 in the 10 highest impact factor surgery journals and the 5 highest impact factor laparoscopic journals. Eligible studies were blindly assessed by two independent investigators using the Scottish Intercollegiate Guidelines Network (SIGN) tool for RCTs. Univariate and multivariate analyses were performed to identify potential associations with methodological quality. A total of 114 relevant RCTs were identified. More than half of the trials were of high or acceptable quality. Half of the reports provided information on comparative demo graphic data and only 21% performed intention-to-treat analysis. RCTs with sample size of at least 60 patients presented higher methodological quality (p = 0.025). Upon multiple regression, reporting on preoperative care and the experience level of surgeons were independent factors of quality.

Laparoscopic versus open obesity surgery: a meta-analysis of pulmonary complications.

The clinical effects of laparoscopy in the pulmonary function of obese patients have been poorly investigated in the past. A systematic review was undertaken, with the objective to identify published evidence on pulmonary complications in laparoscopic surgery in the obese. Outcome measures included pulmonary morbidity, pulmonary infection and mortality. The random effects model was used to calculate combined overall effect sizes of pooled data. Data are presented as the odds ratio (OR) with 95% confidence interval (CI). A total of 6 randomized and 14 observational studies were included, which reported data on 185,328 patients. Pulmonary complications occurred in 1.6% of laparoscopic and in 3.6% of open procedures (OR 0.45, 95% CI 0.34-0.60). Pneumonia was reported in 0.5% and in 1.1%, respectively (OR 0.45, 95% CI 0.40-0.51). Available evidence suggests lower pulmonary morbidity for laparoscopic surgery in obese patients; further quality studies are however necessary to consolidate these findings.

Laparoscopic colorectal surgery confers lower mortality in the elderly: a systematic review and meta-analysis of 66,483 patients.

BACKGROUND: Increasing life expectancy requires specific attention on geriatric patients. Data support a potential reduction of surgical morbidity for patients undergoing laparoscopic surgery as compared to conventional surgery. The aim of this study was to investigate the comparative effect of laparoscopic and open colorectal surgery on geriatric patients. METHODS: A systematic review of electronic information sources was undertaken. Studies that provided outcome data on patients aged 65 years or older, subjected to laparoscopic or open colorectal surgery, were considered. Mortality, morbidity, cardiac and pulmonary complications were the outcome measures of treatment effect. The methodological quality of selected studies was independently appraised by two reviewers. Random effects model was applied to synthesize outcome data. RESULTS: Twenty-seven articles providing data for 66,592 patients were included in the analysis. Patients undergoing laparoscopic surgery had a decreased risk for mortality (2.2 vs. 5.4 %; OR 0.55, 95 % CI 0.44-0.67), overall morbidity (19.3 vs. 26.7 %; OR 0.54, 95 % CI 0.46-0.63), cardiac (4.7 vs. 7.7 %; OR 0.60, 95 % CI 0.39-0.92) and respiratory complications (3.9 vs. 6.3 %; OR 0.67, 95 % CI 0.47-0.95). Sensitivity analysis including reports with similar age, American Society of Anesthesiologists score and/or similar prevalence of cardiopulmonary morbidity between the laparoscopic and the open treatment arm validated the outcome estimates of the primary analysis. CONCLUSIONS: This analysis supports a substantial benefit for elderly patients undergoing laparoscopic in comparison with open colorectal surgery. The comparative effect of either approach on geriatric patients with pulmonary and cardiac comorbidities is a subject of further investigation.